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X-Ray Techniques
X-ray techniques that are used to image the chest include plain x-rays,
fluoroscopy, high-resolution and helical (spiral) CT, and CT angiography.
Chest x-ray
Plain chest x-rays and fluoroscopy are used to provide images of the lungs
and surrounding structures.
Plain chest x-rays provide images of structures in and around the thorax
and are most useful for identifying abnormalities in the heart, lung
parenchyma, pleura, chest wall, diaphragm, mediastinum, and hilum.
They are usually the initial test done to evaluate the lungs. The standard
chest x-ray is taken from back to front (posteroanterior view) to minimize x-
ray scatter that could artifactually enlarge the cardiac silhouette and from
the side of the thorax (lateral view).
Computed tomography
CT defines intrathoracic structures and abnormalities more clearly than
does a chest x-ray. Conventional (planar) CT provides multiple 10-mm
thick cross-sectional images through the thorax. Its main advantage is wide
availability. Disadvantages are motion artifact and limited detail from
volume averaging of tissue within each 10-mm slice.
Ultrasonography
Ultrasonography is often used to facilitate procedures such as
thoracentesis and central venous catheter insertion. Endobronchial
ultrasonography (EBUS) is increasingly being used in conjunction with
fiberoptic bronchoscopy to help localize masses and enlarged lymph
nodes. Diagnostic yield of transbronchial lymph node aspiration is higher
using EBUS than conventional unguided techniques. Ultrasonography is
also very useful for evaluating presence and size of pleural effusions and is
now commonly used at the bedside to guide thoracentesis.
Nuclear Scanning
Nuclear scanning techniques used to image the chest include V/Q
scanning and positron emission tomography (PET).
V/Q scanning
V/Q scanning uses inhaled radionuclides to detect ventilation and IV
radionuclides to detect perfusion. Areas of ventilation without perfusion,
perfusion without ventilation, or matched increases and decreases in both
can be detected with 6 to 8 views of the lungs.
PET
PET uses radioactively labeled glucose (fluorodeoxyglucose) to measure
metabolic activity in tissues. It is used in pulmonary disorders to determine
whether lung nodules or mediastinal lymph nodes harbor tumor (metabolic
staging) and whether cancer is recurrent in previously irradiated, scarred
areas of the lung. PET is superior to CT for mediastinal staging because
PET can identify tumor in normal-sized lymph nodes and at extrathoracic
sites, thereby decreasing the need for invasive procedures such as
mediastinoscopy and needle biopsy. Current spatial resolution of PET is 7
to 8 mm; thus, the test is not useful for lesions < 1 cm. PET reveals
metastatic disease in up to 14% of patients in whom it would not otherwise
be suspected. The sensitivity of PET (80 to 95%) is comparable to that of
histologic tissue examination. False-positive results can occur with
inflammatory lesions, such as granulomas; slowly growing tumors (eg,
bronchoalveolar carcinoma, carcinoid tumor, some metastatic cancers)
may cause false-negative results. Newer combined CT-PET scanners may
become the most cost-effective technology for lung cancer diagnosis and
staging.